In the dusty courtyard of a crowded clinic in Old Fangak, in South Sudan’s Jonglei state, throngs of people, some of them under mosquito nets strung between trees, wait to get tested for kala-azar, amid the worst continuous outbreak in three decades.
Last year, this clinic – which lacks electricity or running water - handled around half the 11,000 total recorded cases of the parasitical disease, also known as visceral leishmaniasis. Spread by the bite of the sand-fly, it can cause fever, weight loss, enlarged spleen, rash, anaemeia, diarrhoea, fatigue and, left untreated, death.
Conflict and poverty facilitate its spread. Kala-azar used to strike in relatively brief outbreaks every 7 to 10 years. But an outbreak that began in 2009 has yet to let up, affecting some 25,000 people, mostly in Jonglei and Upper Nile states.
“It’s because of the current situation in South Sudan, where the humanitarian [situation] is deteriorating,” said Abdi Nasir, head of communicable diseases for the UN World Health Organisation (WHO).
“There’s food insecurity, there’s displacement, many factors. We are expecting that the outbreak may continue” and affect another 11,000 people in 2012, he said.
In the absence of passable roads to Old Fangak, most patients arrive by boat, according to community health worker George Kam Kong.
“But if you don’t have money, then you cannot reach the centre for treatment. So, so many people die at home. Which is why we are asking our government, our NGOs, for more medicines, more supplies, and to bring the road to here,” he added.
In 2011, the mortality rate for treated cases was under three percent. The most effective drug, Ambazom, costs around US$500-600 per patient without factoring in expensive transportation.
WHO is rushing to preposition drugs in places such as Old Fangak before rains render the town’s runway unusable.
“We have documented people who have felt sick and then two weeks later were dead. That’s how aggressive our disease is here,” explained Jill Seaman, an independent US doctor who has spent the better part of every year in Jonglei since a 1989 kala-azar outbreak killed half the population of the area surrounding Old Fangak.
“Watching all the skeletal people walking into the clinic [then] every night to get treated and asking them, ‘How many people in your family have died?’ and hearing the answer, ‘12, 14 , 8, 13,’ it kind of bonds you to a community, and I suppose that’s why I’m still here,” she told IRIN.
“It’s very, very deadly without treatment. They say 95 or more percent of people who get infected with kala-azar will die [without treatment]. Mostly they get sicker and sicker, they get more malnourished, [so] they get more and more infectious diseases, and then they die.”
Photo: Hannah McNeish/IRIN
|Costly but effective: Treatment reduces mortality to around three percent but costs up to $600 per patient|
In one of the clinic’s dim wards, where several people squeeze onto each single bed, Nyadak Mouk recounted how she walked eight hours from the village of Keew to come here six months ago to treat her five-year-old son.
Over the past five years, Mouk has lost four other children aged under 10.
“I don’t know what they died of as I didn’t bring them to the clinic. They died in the village. A lot of people died in my village and they don’t go to the clinic,” she said.
Only between 30 and 40 percent of people in South Sudan have access to primary health care.
Mouk said she had come to Old Fangak’s clinic four times over the last year to get herself or her son treated for kala-azar.
“I now live near the clinic. I can’t be away from it as without treatment he will die,” she said, cradling her son.
Part of last year’s caseload has been attributed to widespread displacement caused by clashes between government troops and forces loyal to a renegade general George Athor.
“People leave their homes and then they live under trees, without clothes, without mosquito nets” and get bitten, explained Kong .
Athor’s men are supposed to have been absorbed into the army under an amnesty agreed following Athor’s battlefield death in December 2011, but by many accounts, most of them – and they are said to number in the thousands – are still at large.
“To clean up kala-azar in your body, you have to have proper nutrition, or you’ll just get it again”, said Seaman, adding that nutrition in the area had been greatly compromised in 2011 by militias looting food supplies and then by widespread crop failures.
“We have no backup food and no food right now. WFP [the UN’s World Food Programme] has trouble getting us any food, the supply of Plumpy’Nut [a ready-to-eat therapeutic food] for the severely malnourished [has stopped], and we are really, really in trouble for nutritional support” she said.
According to Elijah Hon Riak, the clinic’s nutrition advisor, “the people get a low immune system because they did not have food, so it is easier to get kala-azar.”
“It affects health as many people come to the clinic and they are malnourished” and this affects recovery rates,” he said.
Nyakouth Majiok, whose four-year-old daughter has had a fever since December 2011, and now lies in the clinic recovering from kala-azar, wailing from heavy nosebleeds, recalled that last year “we got no crops, they were destroyed by the flooding. This year it is very difficult to get food.”
“We buy food from the north [Sudan] but if you don’t have money then it’s a problem. The food we are using is cow’s milk and water lily we get in the river,” she said.
As well as conflict and crop failure, food security across South Sudan has been exacerbated by the return, since the country gained independence from Sudan in July 2011, of some 350,000 people who had fled during the 1983-2005 civil war.
According to the town’s chief, Kuol Samuel Gai, the town’s population had increased by 10,000 people, to 30,000.
“They come from the north without food, without shelter….We also have so many displaced people coming and we don’t have enough food to share with them,” he told IRIN.
Gai explained that the closure of the border with Sudan had led to the doubling of the price of the sorghum, a staple.
“I am capable with all of my friends here, and the national staff of trying to take care of the medical issues, but the food issue is way beyond us,” said Seaman.
Unlike countries such as India, which is making progress towards eradicating kala-azar, in South Sudan the disease is still on the march, possibly, according to Seaman, because of a suspected animal reservoir, and also because untreated related skin infections can thrive for years.
“The main reason you can’t get rid of it in a place like this is of course that it’s a disease of poverty. We need to do something about poverty, be able to sleep in a protected environment, to have access to food so you don’t get malnourished and get the disease more quickly,” said Seaman.
“One thing I know,” said Mouk, “is that if we receive the mosquito nets, people will live under them and we can reduce it.”